Bike Fit Intake Questionnaire
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Last Name, First Name *
Phone # *
Email *
Address *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Marital Status *
Occupation *
Emergency Contact (Name, Phone Number) *
Primary Care Provider (Name, Facility Name/Location)
Texas is a Direct Access state, meaning a referral for physical therapy is NOT required to start PT, however, we are required to get one in order to continue beyond two weeks from your evaluation session. This is a requirement of our state board, and it has nothing to do with insurance. A referral can come from a physician, nurse practitioner, podiatrist, dentist, or chiropractor. Often you may not need to go in for an office visit, however every provider is different. Referrals can be sent to our fax (855-574-0792) or to our encrypted email inbox (info@latitudept.com).
Specialist Provider (Name, Facility Name/Location)
Do you plan to request reimbursement for out-of-network benefits from your insurance company? *
Latitude Physiotherapy does not contract with any insurance companies, however, the payments you make may be partially reimbursable by your insurance company if your plan includes out-of-network physical therapy benefits. If you want to use out-of network benefits, download the Insurance Benefits Worksheet and call your insurance prior to initiating physical therapy—some insurance companies will deny your claims if you don't follow their instructions carefully. There is a $5 service fee per visit/superbill.
How did you hear about Latitude Physiotherapy? *
The following is very important to our evaluation process and to help you achieve an optimal bike fit. Do your best to provide us with a clear picture of your current symptoms, functional status, and cycling history.
What is the primary problem you are dealing with? *
Are there any secondary problems?
Specifically, where are you experiencing symptoms? *
What words do you use to describe your symptoms? (i.e., dull, aching, sharp, stabbing, burning, numbness, tingling, weakness, tightness) *
WHEN and HOW did your symptoms begin? *
Did you experience a trauma (physical or emotional) or a change in your routine around the time your symptoms began? *
“As a result, I am having difficulty with… (i.e., everyday activities, recreation, sports).” Separate each activity/task on a new line. *
*Format: Task or Activity / Tolerance (i.e., minutes, reps)
Symptom Scale
Please rate your symptoms based upon the last 48 hours using a 0-10 scale. 0 is nothing, while 10 is the worst imaginable.
At its worst *
At its best *
At present *
When are your symptoms the worst? (i.e., time of day, during an activity or movement) *
When are your symptoms the best? (i.e., time of day, during an activity or movement) *
Does anything else aggravate your symptoms? *
Have you found anything that alleviates your symptoms? *
Have you received diagnostic imaging for this problem (i.e., X-ray, MRI, CT scan)? *
Cycling History
How long you have been riding, and what kind of experience do you have? *
Describe your cycling training volume (i.e., weekly mileage or training hours, # of easy rides vs. workouts and group rides, etc.). *
How long is your typical long ride (distance or time)? *
Do your routes tend to be mostly hilly, flat, or mixed? *
What kind of events are you training for (distance, terrain, hilly, flat, etc.)? *
How long have you had the bike we're fitting today? *
Who set it up for you? *
What do you like about your current set-up (i.e., fit, handling, components, etc.)? *
What don't you like about your current set-up (i.e., fit, handling, components, etc.)? *
Have you tried changing anything to improve your comfort or fit on your bike? *
MOVE:
"Move" pertains to your movement routine including exercise or other movement you engage in regularly.
Describe your exercise and movement routine before your symptoms began (type, frequency, duration) *
Describe your current exercise and movement routine (type, frequency, duration) *
Briefly describe a typical day at work (i.e., activities you engage in, sitting, standing, field work, etc.) *
FUEL:
"Fuel" pertains to how you sustain your body.
Briefly describe your diet. *
What is your daily fluid intake in liters on average? *
How many alcoholic drinks do you have per week on average? *
One drink = 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor
How would you rate your sugar intake? *
RECOVER:
“Recover” pertains to activities that aid your recuperation.
How many hours do you normally sleep per night? *
Do you feel rested when you wake up in the morning? *
ENDURE:
"Endure" pertains to our response to adversity.
Are there any behaviors you engage in when stressed that you think could be problematic? *
Are there any proactive strategies you use to deal with stress? *
CONNECT:
"Connect" pertains to your support structures and spheres of influence.
Please rate the strength of your social relationships: *
Medical History
What other treatments have you had for this problem? *
Required
Were those treatments helpful?
Does your medical history include any of the following conditions? Check all that apply. *
Required
Please provide details for the boxes checked above, including the date(s) of occurrence.
List your current medications and supplements. Please separate each on a new line. *
*Format: Medication / For treatment of… / Dose / Effectiveness
Do you smoke tobacco? *
Is there a chance you could be pregnant at this time? *
Goals: List the activities that you would like to be able to do after completing physical therapy. Please separate each goal on a new line. *
*Format: Task or Activity / Duration or How Often / By When
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